A Stitch in Time

1. A Stitch in Time…….
Cardiovascular Diseases
Vash Mungal-Singh
vash@heartfoundation.co.za

2.  CVDs are the leading causes
of death and disability in the
world.
 Although a large proportion
of CVDs is preventable, they
continue to rise mainly
 An estimated 17.3 million because preventive measures
people died from CVDs in are inadequate.
2008 WHO 2011
 Over 80% of CVD deaths
take place in low- and middle-
income countries
 By 2030, almost 23.6 million
people will die from CVDs

3. SA’s Burden
Causes Deaths Years of Life Lost
(000) (%) (%)
HIV/AIDS 355 52 63
Cerebrovascular disease 30 5 2
Ischaemic heart disease 27 4 2
Lower respiratory infections 23 4 3
Violence 19 3 3
Tuberculosis 14 2 2
Diarrhoeal diseases 13 2 3
Road traffic accidents 13 2 2
Diabetes mellitus 12 2 1
COPD 9 1 1

4. SA’s Burden of Risk Factors
Risk factor Estimated number affected
Smoking tobacco 7.7 million
High BMI 9.1 million
Hypertension 6.3 million
Diabetes II 0.9 million
High blood cholesterol 7.9 million
Low fruit and veg 13.4 million
Physical inactivity 13.6 million
Source: South African Comparative Risk Assessment
Norman et al, 2007
Thanks to Debbie Bradshaw, MRC

5. WHO and World Bank data
(Walter et al. 2006)
Predict that over the next 30 years not only will there be
an almost doubling of deaths due to CVD in South Africa
but that an increasing proportion of these will be
amongst the working age group (ages 35-64) compared to
other age groups

6. CVD: Key Points
 80% of premature CVDs are  Modification of risk factors
preventable……..lifestyle reduces mortality and
changes morbidity in people with
diagnosed or undiagnosed
CVD
 The major modifiable risk
factors for CVD are known
 Tobacco use
 Directly controlling blood
pressure, total cholesterol, and
 Sedentary lifestyle smoking leads to rapid and
 Unhealthy diet substantial reductions in CVD
 Harmful use of alcohol rates  Therefore focusing on
controlling these three risk
factors will rapidly and to a large
 Yet…..unhealthy behaviours extent reduce CVD globally
continue to be adopted by within a few years (Lancet 2011)
both individuals and
communities

7. DALYs gained over time, per
intervention
The Lancet 2010, Vol 376

8. Multi-Layered complexity of causes
…from…Preventing Chronic Diseases: a vital investment. Geneva, World Health Organization, 2005.

9. Framework for promoting healthy lifestyles
Primordial Primordial Primary Secondary
prevention prevention prevention prevention
Population Community Early Cost-
wide based diagnosis and effective
interventions to interventions cost-effective management
promote to promote management of high risk
healthy healthy of high risk individuals
lifestyles in the lifestyles and individuals;
whole change includes the
population behaviours health sector
Determinants Unhealthy Metabolic risk Morbidity and end Mortalit
of health lifestyle factors organ damage y
-Social and -Diet -Overweight -Cardiovascular
economic -Alcohol use and obesity disease
-Environmental -Tobacco use -Hypertension -Renal disease
-Genetic factors -Physical -Dyslipidemia -Eye disease
-Intra-uterine Activity -Poor glucose -Respiratory disease
environment control -Cancer
-Mental illness
Figure 1: Schematic framework for promoting healthy lifestyles and preventing NCDs
Source: Adapted from Steyn and Bradshaw, 2001

10. Drivers of Risk Factors

11. Drivers of Risk Factors
Physical Activity Patterns
in SA Youth

12. Drivers of Risk Factors in
Children
Physical Activity
 Participation in physical education and physical activity -  from 2007
 < 70% of high-school learners have regularly scheduled PE
Unhealthy diet
 >50% of learners drank sweetened cool drinks often (> 4 times/wk)
 +/- 20% of advertising time on SA television is related to food, over half of
which is of poor nutritional value
Tobacco
 While smoking prevalence rates have decreased overall since the anti-
tobacco legislation, little effect is noted in youth
 Despite the good smoking legislation and policy, very little formal tobacco
prevention or cessation interventions for adolescents and children
 Smoking is addressed in the national curriculum (life orientation), but even
so is not receiving adequate attention in the school setting

13. Is the right choice the easy
choice?
Access to health foods
 Shortage of healthy low-fat food and little fresh fruit and vegetables in townships.
 Most local shops sell cheap fatty foods.
 Healthy foods prohibitively expensive, processed foods exceedingly cheap
Advertising
 Supermarkets make healthy foods available BUT low prominence
 Supermarkets offer more shelf space to fruits and vegetables than other stores, BUT
devote nearly double the shelf space to snack items vs. fruits and vegetables
 82% of all food promotions in supermarkets were for unhealthy foods  Children are
main target audience i.e. 100% of supermarket promotions in confectionery, sweet biscuits,
chips/savoury snacks, dairy products, and ice cream were directed at children
Perceptions
 “I am scared of exercising because I will lose weight and people may think that I have
HIV/AIDS.”
 “People who boil food are not civilised. Fried food is attractive and tasty such as “Kentucky
Fried Chicken”. If your neighbour boils food people say she is still backward because the
food does not taste nor look attractive”
Chopra M, Puoane T. Diabetes Voice 2003; 48: 24–6.
Temple, et. al., "Price and availability of healthy food: A study in rural South Africa." Nutrition Journal 1 (2010): 1-4. Farley et. al.. "Measuring the

14. Multi-pronged, inter-sectoral, multi-
generational, evidence-based,
collaborative approach
Schools Work places Government Community
Dietary policy School Nutrition Programme, Canteens, vending machines,
and guidelines catering for meetings and events
Other policies Physical Activity programs, smoking free zones
Healthy Lifestyles Curriculum
Empowerment
Healthy Lifestyles advice/group sessions
Parental involvement, employee committee involvement, community involvement
Advocacy Multi-media messaging to promote healthy lifestlyes
Structural Food Security, subsidies/incentives for healthy foods in deprived areas, urban design that
promotes physical activity, incentives for workplaces, safety and security

15. What else do we know? 4 x 4
4 Risk Factors 4 Diseases NON-COMMUNICABLE
DISEASES (NCDs)
 Tobacco use  CVD
 Unhealthy diets  Diabetes
 Lack of physical activity  Cancer
 Harmful use of alcohol  Chronic Lung diseases
“at least 80% of heart disease, stroke, and Type 2 diabetes, and 40% of cancer
could be avoided through healthy diet, regular physical activity, and avoidance of
tobacco use”
(Strong 2005)

16. Non-Communicable Diseases
– 60% (35 million) of global
deaths
– 75% of all deaths by 2030
– More than 80% of deaths in
low and middle income
countries (LMIC’s)
– Amongst the top 10 causes of
premature mortality in South
Africa
– 28% of deaths in 2002

17. Barriers
 Little collaboration between various stakeholders
 NGO’s often work in isolation of district, provincial and national structures
 Silo, non-collaborative approach
 non-alignment of strategies
 duplication of efforts creating message fatigue
 inefficient use of resources (funding, people, and infrastructure)
 Regional pockets of interventions  limited reach of the population
 Reluctance to share information
 No clear regulatory, monitoring and reporting mechanisms
 Accountability and transparency at the discretion of individuals or organisations
 varying standards and interpretations
 No agreed overarching objectives
 Funding challenge  a competitive landscape and reluctance to
collaborate and share information

18. Going Forward
a unified voice for
a regulatory environment
collective action
pooling and coordination
agreed targets and
of expertise and
outcomes
resources
coordinated collaboration
a formal interface
with national and partnerships with the
between all relevant
provincial governments private sector
stakeholders
and districts

19. Effectiveness and cost effectiveness of cardiovascular disease
prevention in whole populations: modelling study
BMJ 2011;343:d4044 doi: 10.1136/bmj.d4044
What is already known on What this study adds
this topic
 A national programme reducing population
 Population-wide prevention cardiovascular risk by 1% would prevent
programmes, such as salt reduction, approximately 25 000 CVD cases and
trans fat eradication, or smoke-free generate public sector savings of about
£30m a year
legislation seem to be very effective for
preventing CVD  Reducing mean population cholesterol or
blood pressure levels by 5% (as already
achieved in some other countries) would
 Studies in the United States and result in annual savings of approximately
Australia suggest that as well as £80m or £100m
reducing CVD events and deaths, such  Legislation or other measures to reduce
programmes may also be cost saving dietary salt intake by 3 g/day or industrial
trans fatty acid intake by approximately 0.7%
of total energy content would save about
£40m or £230m a year

20. It makes sense at all levels, even
economic
Effectiveness and cost effectiveness of cardiovascular disease
prevention in whole populations: modelling study
BMJ 2011;343:d4044 doi: 10.1136/bmj.d4044
 Generic population-wide interventions  Reducing
CVD risk of the population by just 1% sustained over
10 years
 Prevent approximately 25 000 new cases of and 3500 deaths
from CVD
 Gain around 98 000 QALYs
 Annual savings across the 10 years of the programme of
approximately £30m

21. Thank You